Diagnostic Accuracy of Corneal and Epithelial Thickness Map Parameters to Detect Keratoconus and Suspect Keratoconus.

Aim: To establish the diagnostic accuracy of corneal and epithelial thickness measurements obtained by spectral-domain optical coherence tomography (SD-OCT) in detecting keratoconus (KC) and suspect keratoconus (SKC). Methods: This retrospective study reviewed the data of 144 eyes separated into three groups by the Sirius automated corneal classification software: normal (N) (n = 65), SKC (n = 43), and KC (n = 36). Corneal thickness (CT) and epithelial thickness (ET) in the central (0-2 mm) and paracentral (2-5 mm) zones were obtained with the Cirrus high-definition OCT. Areas under the curve (AUC) of receiver operator characteristic (ROC) curves were compared across groups to estimate their discrimination capacity. Results: ROC curve analysis revealed excellent predictive ability for ET variables: minimum (Min) ET (0_2), minimum-maximum (Min-Max) ET (0_2), superonasal-inferotemporal (SN-IT) ET (2_5), Min-Max ET (2_5), and Min ET (2_5) to detect keratoconus (AUC > 0.9, all). Min-Max CT (0_2) was the only CT parameter with excellent ability to discriminate between KC and N eyes (AUC = 0.94; cutoff = ≤-32 µm). However, both ET and CT variables were not strong enough (AUC < 0.8, all) to differentiate between SKC and N eyes, with the highest diagnostic power for Min-Max ET (2_5) (AUC = 0.71; cutoff = ≤-9 µm) and central corneal thickness (CCT) (AUC = 0.76; cutoff = ≤533 µm). Conclusion: These results demonstrate that OCT-derived CT and ET are able to differentiate between KC and N eyes, with a high level of certainty. However, Min-Max ET (2_5) was the parameter with the highest ability to detect suspect keratoconus.

Corneal higher order aberrations by Sirius topography and their relation to different refractive errors.

PURPOSE: To compare the root mean square (RMS) of anterior corneal higher-order aberrations (HOAs) in ametropic and emmetropic eyes. METHODS: This retrospective observational study was conducted at the Department of Ophthalmology, Tishreen University Hospital, Latakia, Syria. Study eyes were divided into four groups based on refractive error: mild-to-moderate myopia, hypermetropia, myopic astigmatism, and emmetropic eyes as controls. The following anterior corneal HOAs were evaluated using the Scheimpflug-Placido Sirius (CSO, Italy) tomographer over 6 mm pupil: Root mean square (RMS) total corneal HOAs, RMS trefoil, RMS coma and RMS spherical aberrations. RESULTS: RMS values of total HOAs, trefoil and coma showed statistically significant differences in all four groups (P < 0.05, all). HOAs were noted to be lowest in the control group (0.18 ± 0.09, 011 ± 0.08 and 0.09 ± 0.08 µm, respectively) and highest in the myopic astigmatism group (0.31 ± 0.16, 0.15 ± 0.12, 0.17 ± 0.14 µm, respectively). RMS spherical aberration was lowest in the astigmatism group (0.00 ± 0.16 µm) with a statistically significant difference from that in the control group (0.05 ± 0.07 µm, P = 0.049). CONCLUSION: The mean RMS values of total HOAs, trefoil and coma were highest in the astigmatism group and lowest in the control group. However, spherical aberration was minimal in the astigmatism group. A better understanding and targeted treatment of higher-order aberrations in ametropic human eyes, and in particular eyes with astigmatism, may enhance visual quality and performance in the treatment of refractive errors. Recognising atypical HOAs may also assist in the early detection of pathological conditions such as keratoconus.

Prevalence of Keratoconus and Keratoconus Suspect among Patients Seeking Refractive Surgery in Syria.

PURPOSE: The purpose of this study was to determine the prevalence of keratoconus (KC) and keratoconus suspect (KCS) among patients seeking refractive surgery in Syria. METHODS: This is a retrospective multicenter screening study. The study was conducted in Damascus University, Tishreen University, and Tartous Specialist Eye Center (a private center). Data were collected from refractive surgery candidates referred for preoperative evaluation before laser in situ keratomileusis, photorefractive keratectomy, intrastromal corneal rings, and phakic intraocular lens implantation. Corneal parameters were obtained by Scheimpflug-Placido tomography, Sirius (CSO, Italy). RESULTS: A total of 1479 patients were included in this analysis. The prevalence rates of KC and KCS were 18.19% (269/1479) and 13.52% (200/1479), respectively. In addition, patients with KC were found to have higher percentages of eye rubbing and astigmatism than suspect and normal (P < 0.0001). CONCLUSION: High prevalence rate of KC was found among patients seeking refractive surgery in Syria. Although this study was carried out on a highly selective population, it may reflect a high prevalence rate in a general population in Syria.

Clinical Outcomes of Accelerated Corneal Cross-Linking for Pediatric Keratoconus.

AIM: To assess the efficacy and safety of accelerated corneal cross-linking in the treatment of pediatric keratoconus. METHOD: In this retrospective case series, 29 eyes of 20 pediatric patients with keratoconus underwent accelerated corneal cross-linking. Treatment was delivered at 10 mW/cm2 for 9 minutes with a total dose of 5.4 J/cm2. Clinical evaluation included visual acuities and refractive and Scheimpflug corneal tomography assessments. All patients with a minimum follow-up duration of 24 months were included in the study. RESULTS: Mean ± standard deviation age was 15.41 ± 2.13 years (range: 8 to 18 years). Uncorrected distance visual acuity improved significantly from 0.56 ± 0.28 to 0.42 ± 0.29 logMAR (P=0.0003), and corrected distance visual acuity improved significantly from 0.34 ± 0.23 to 0.28 ± 0.22 logMAR (P=0.014). The mean manifest refraction spherical equivalent value was significantly reduced (-0.59 ± 0.95 D, P=0.0024). While mean flat keratometry and steep keratometry values were not significantly altered (P > 0.05 for both), the mean maximum keratometry value was significantly decreased from 56.97 ± 5.24 D preoperatively to 55.84 ± 5.37 D at 24 months postoperatively (P=0.003). Maximum keratometry had progressed by >1 D in two eyes (6.89%). Permanent corneal haze was reported in one case (3.44%). CONCLUSION: Our 24-month follow-up demonstrated that accelerated corneal cross-linking appears to halt the progression of keratoconus in pediatric patients without apparent complications. Uncorrected and corrected distance visual acuities were also improved.

Factors associated with the intention of Syrian adult population to accept COVID19 vaccination: a cross-sectional study.

BACKGROUND AND OBJECTIVES: With global efforts to develop and deliver a COVID-19 vaccine rapidly, vaccine hesitancy stands as a barrier to these efforts. We aimed to estimate the proportion of Syrian adult population intending to be vaccinated against COVID-19 and, principally, to assess the demographic and attitudinal factors associated with it in order to approach suitable solutions. METHODS: An anonymous online questionnaire was conducted between 23rd December 2020 and 5th January 2021 in various provinces in Syria. A total of 3402 adults were sampled to reflect the population demographic factors. Attitudinal factors included Covid-19 fears, risks, and beliefs on the origin. Vaccination hesitancy and knowledge were also measured. The intention to get vaccinated against COVID-19 was the primary endpoint. RESULTS: According to their statements, 1222 participants (35.92%) will consent to get vaccinated against COVID-19. Our findings indicate that male gender, younger age, rural residence, not having children, smoking, fear about COVID-19, individual perceived severity, believing in the natural origin of the coronavirus, and high vaccination knowledge were positive predictors of embracing COVID-19 vaccine when it is available. CONCLUSION: COVID-19 vaccine acceptance rate is considerably poor across Syrian population compared to populations in developed countries. Vaccine hesitancy is closely bound to the fear of side effects and doubts about vaccine efficacy. Factors such as conspiracy beliefs and myths about the vaccine lower vaccine uptake. Thus, interventional educational campaigns are increasingly required to overcome misinformation and avert low vaccination acceptance rates.

Workplace violence toward resident doctors in public hospitals of Syria: prevalence, psychological impact, and prevention strategies: a cross-sectional study.

INTRODUCTION: Workplace violence (WPV) against healthcare workers is a common and daily problem in hospitals worldwide. Studies in different countries indicated that exposure to WPV potentially impacts the psychological status of healthcare workers. However, there is a paucity of studies approaching this issue in the Syrian healthcare system. OBJECTIVES: This study had three objectives: (1) to estimate the prevalence of violence against resident doctors in Syria, (2) to examine the association between WPV and resident doctors' psychological stress, sleep quality, depression, and general health and (3) to suggest approaches to tackle this problem from the resident doctors' perspectives. METHODS: A cross-sectional study was conducted in 8 out of 14 provinces, and covered 17 out of 56 accessible functioning hospitals in Syria. Data were collected using anonymous, self-administered questionnaires during February 2020. A total of 1226 resident doctors volunteered to participate in the study. Finally, 1127 valid questionnaires were used in the final data analysis. The overall response rate was 91.92%. RESULTS: A total of 955 participants (84.74%) reported exposure to WPV in the 12 months prior to the study. In specific, 84.74% exposed to verbal violence and 19.08% to physical violence. Patients' associates were the predominant aggressors in both verbal and physical violence (n = 856; 89.63%, n = 178; 82.79%, respectively). Most resident doctors (87.31%) suggested enacting more legislation to protect doctors as the best solution to reduce WPV. Verbal and physical violence showed a significant positive correlation with each item of depression and stress, and a significant negative correlation with both subjective sleep quality and subjective health. CONCLUSION: Workplace violence against resident doctors in Syria is highly common. Therefore, policymakers, hospital managers, and supervisors should work collaboratively in order to minimize WPV and ensure resident doctors' safety and psychophysical stability.

Visceral and Cutaneous Leishmaniases in a City in Syria and the Effects of the Syrian Conflict.

War provides ideal grounds for the outbreak of infectious diseases, and the Syrian war is not an exception to this rule. Following the civil crisis, Syria and refugee camps of neighboring countries witnessed an outbreak of leishmaniasis. We accessed the database of the central leishmaniasis registry in Latakia city and obtained the leishmaniasis data of the period 2008-2016. Our data showed that the years 2013 and 2014 recorded a surge in the number of both cutaneous leishmaniases (CL) and visceral leishmaniasis (VL) cases. This surge coincided with the massive internal displacement waves that struck Latakia governorate during that time. Subsequently, after 2015, the number of recorded CL and VL cases gradually decreased. This drop coincided with a reduced influx of internally displaced persons into Latakia governorate. Our report depicts the effects of the Syrian crisis on the epidemiology of leishmaniasis by outlining the experience of Latakia governorate. Similar results may have occurred in other refugee-hosting Syrian governorates.

Improving the quality of hospital care provided for asthma out-patients in a country in turmoil: a report from Syria.

BACKGROUND: In low resources settings, especially during periods of turmoil, asthma care becomes emergency-oriented, and adherence to international asthma management guidelines such as long-term inhaled corticosteroids (ICS) prescription is limited. The role of education for inhaler technique to guarantee treatment efficacy is neglected and follow up is hampered by war-related displacement. In Syria, asthma care is not included in primary care, and frequently, internal medicine general hospital outpatient clinics are the first contact. The main objective of our study was to evaluate the adequacy of prescription of controller medications (ICS/LABA) by residents on initial contact with patients, and the effect of regular onsite personalized supervision and coaching by a trainer pulmonologist on improving their practice. The second objective was to evaluate the efficacy of mobile training for inhaler technique, and asthma mobile follow up. METHODS: We developed an audit form to assess initial prescription of ICS/LABA by residents. Filled forms were reviewed by a trainer pulmonologist for compliance with international guidelines. When discrepancies were noted, onsite training was provided. Auditing of new presenting asthma patients is continual to evaluate improvement of initial prescription by the same residents. In parallel, video-mobile education of patients for inhaler technique, and mobile interviewing follow up were tested. RESULTS: Implementation of these strategies resulted in improved adherence of residents to ICS dosing guidelines (P=0.002), optimal inhaler technique by patients, and efficacy of mobile follow up. CONCLUSIONS: WHO programs for CRD in developing countries, especially in regions of conflict and war, should include auditing of care by residents with onsite coaching by trainer pulmonologists, and mobile education for technology of inhaler and patient follow up.

Impact of active and passive smoking as risk factors for asthma and COPD in women presenting to primary care in Syria: first report by the WHO-GARD survey group.

BACKGROUND: The burden of chronic respiratory disease (CRD) is alarming. International studies suggest that women with CRD are undersurveyed and underdiagnosed by physicians worldwide. It is unclear what the prevalence of CRD is in the general population of Syria, particularly among women, since there has never been a survey on CRD in this nation. The purpose of this study was to investigate the impact of different patterns of smoking on CRD in women. MATERIALS AND METHODS: We extracted data on smoking patterns and outcome in women from the Global Alliance Against Chronic Respiratory Diseases survey. Using spirometric measurements before and after the use of inhaled bronchodilators, we tracked the frequency of CRD in females active and passive narghile or cigarette smokers presenting to primary care. We administered the questionnaire to 788 randomly selected females seen during 1 week in the fiscal year 2009-2010 in 22 primary care centers in six different regions of Syria. Inclusion criteria were age >6 years, presenting for any medical complaint. In this cross-sectional study, three groups of female subjects were evaluated: active smokers of cigarettes, active smokers of narghiles, and passive smokers of either cigarettes or narghiles. These three groups were compared to a control group of female subjects not exposed to active or passive smoking. RESULTS: Exposure to active cigarette smoke but not narghile smoke was associated with doctor-diagnosed chronic obstructive pulmonary disease (COPD). However, neither cigarette nor narghile active smoking was associated with increased incidence of spirometrically diagnosed COPD. Paradoxically, exposure to passive smoking of either cigarettes or narghiles resulted in association with airway obstruction, defined as forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) < 70% according to the Global initiative for chronic Obstructive Lung Disease criteria; association with FEV1 < 80% predicted, evidencing moderate to severe GOLD spirometric grade, and doctor-diagnosed COPD. Physicians tend to underdiagnose COPD in women who present to primary care clinics. Whereas around 15% of enrolled women had evidence of COPD with FEV1/FVC < 70% after bronchodilators, only 4.8% were physician-diagnosed. Asthma did not appear to be a significant spirometric finding in these female subjects, although around 11% had physician-diagnosed asthma. One limitation is FEV1/FVC < 70% could have also resulted from uncontrolled asthma. The same limitation has been reported by the Proyecto Latinoamericano de Investigacion en Obstruccion Pulmonar (PLATINO) study. CONCLUSION: Contrary to popular belief in developing countries, women exposed to tobacco smoke, whether active or passive, and whether by cigarettes or narghiles, like men are at increased risk for the development of COPD, although cultural habits and taboos may decrease the risk of active smoking in some women. RECOMMENDATIONS: These findings will be considered for country and region strategy for noncommunicable diseases, to overcome underdiagnosis of CRD in women, fight widespread female cigarette and narghile smoking, and promote behavioral research in this field.

Rhinitis and onset of asthma: a longitudinal population-based study.

BACKGROUND: A close relation between asthma and allergic rhinitis has been reported by several epidemiological and clinical studies. However, the nature of this relation remains unclear. We used the follow-up data from the European Community Respiratory Health Survey to investigate the onset of asthma in patients with allergic and non-allergic rhinitis during an 8.8-year period. METHODS: We did a longitudinal population-based study, which included 29 centres (14 countries) mostly in western Europe. Frequency of asthma was studied in 6461 participants, aged 20-44 years, without asthma at baseline. Incident asthma was defined as reporting ever having had asthma confirmed by a physician between the two surveys. Atopy was defined as a positive skin-prick test to mites, cat, Alternaria, Cladosporium, grass, birch, Parietaria, olive, or ragweed. Participants were classified into four groups at baseline: controls (no atopy, no rhinitis; n=3163), atopy only (atopy, no rhinitis; n=704), non-allergic rhinitis (rhinitis, no atopy; n=1377), and allergic rhinitis (atopy+rhinitis; n=1217). Cox proportional hazards models were used to study asthma onset in the four groups. FINDINGS: The 8.8-year cumulative incidence of asthma was 2.2% (140 events), and was different in the four groups (1.1% (36), 1.9% (13), 3.1% (42), and 4.0% (49), respectively; p<0.0001). After controlling for country, sex, baseline age, body-mass index, forced expiratory volume in 1 s (FEV(1)), log total IgE, family history of asthma, and smoking, the adjusted relative risk for asthma was 1.63 (95% CI 0.82-3.24) for atopy only, 2.71 (1.64-4.46) for non-allergic rhinitis, and 3.53 (2.11-5.91) for allergic rhinitis. Only allergic rhinitis with sensitisation to mite was associated with increased risk of asthma independently of other allergens (2.79 [1.57-4.96]). INTERPRETATION: Rhinitis, even in the absence of atopy, is a powerful predictor of adult-onset asthma.

Allergic rhinitis and onset of bronchial hyperresponsiveness: a population-based study.

RATIONALE: Patients with allergic rhinitis have more frequent bronchial hyperresponsiveness (BHR) in cross-sectional studies. OBJECTIVES: To estimate the changes in BHR in nonasthmatic subjects with and without allergic rhinitis during a 9-year period. METHODS: BHR onset was studied in 3,719 subjects without BHR at baseline, who participated in the follow-up of the European Community Respiratory Health Survey. MEASUREMENTS AND MAIN RESULTS: BHR was defined as a >or=20% decrease in FEV(1) for a maximum dose of 1 mg of methacholine. Allergic rhinitis was defined as having a history of nasal allergy and positive specific IgE (>or=0.35 IU/ml) to pollen, cat, mites, or Cladosporium. The cumulative incidence of BHR was 9.7% in subjects with allergic rhinitis and 7.0% in subjects with atopy but no rhinitis, compared with 5.5% in subjects without allergic rhinitis and atopy (respective odds ratios [OR] and their 95% confidence intervals [95% CI] for BHR onset, 2.44 [1.73-3.45]; and 1.35 [0.86-2.11], after adjustment for potential confounders including sex, smoking, body mass index and FEV(1)). Subjects with rhinitis sensitized exclusively to cat or to mites were particularly at increased risk of developing BHR (ORs [95% CI], 7.90 [3.48-17.93] and 2.84 [1.36-5.93], respectively). Conversely, in subjects with BHR at baseline (n = 372), 35.3% of those with allergic rhinitis, compared with 51.8% of those without rhinitis had no more BHR at follow-up (OR [95% CI], 0.51 [0.33-0.78]). BHR "remission" was more frequent in patients with rhinitis treated by nasal steroids than in those not treated (OR [95% CI], 0.33 [0.14-0.75]). CONCLUSIONS: Allergic rhinitis was associated with increased onset of BHR, and less chance for remission except in those treated for rhinitis.

Physical activity and bronchial hyperresponsiveness: European Community Respiratory Health Survey II.

BACKGROUND: Identification of the risk factors for bronchial hyperresponsiveness (BHR) would increase the understanding of the causes of asthma. The relationship between physical activity and BHR in men and women aged 28.0-56.5 years randomly selected from 24 centres in 11 countries participating in the European Community Respiratory Health Survey II was investigated. METHODS: 5158 subjects answered questionnaires about physical activity and performed BHR tests. Participants were asked about the frequency and duration of usual weekly exercise resulting in breathlessness or sweating. BHR was defined as a decrease in forced expiratory volume in 1 s of at least 20% of its post-saline value for a maximum methacholine dose of 2 mg. RESULTS: Both frequency and duration of physical activity were inversely related to BHR. The prevalence of BHR in subjects exercising or=4 times a week was 14.5%, 11.6% and 10.9%, respectively (p<0.001). The corresponding odds ratios were 1.00, 0.78 (95% CI 0.62 to 0.99) and 0.69 (95% CI 0.50 to 0.94) after controlling for potential confounding factors. The frequency of BHR in subjects exercising <1 h, 1-3 h and >or=4 h a week was 15.9%, 10.9% and 10.7%, respectively (p<0.001). The corresponding adjusted odds ratios were 1.00, 0.70 (95% CI 0.57 to 0.87) and 0.67 (95% CI 0.50 to 0.90). Physical activity was associated with BHR in all studied subgroups. CONCLUSIONS: These results suggest that BHR is strongly and independently associated with decreased physical activity. Further studies are needed to determine the mechanisms underlying this association.

Change in C-reactive protein levels and FEV1 decline: a longitudinal population-based study.

Reduced pulmonary function is an important predictor of cardiovascular morbidity and mortality. The mechanisms underlying this association are unknown but may involve systemic inflammation. We assessed the cross-sectional and longitudinal relationships between C-reactive protein (CRP) levels and forced expiratory volume in 1s (FEV1) and its decline in the general population, over a period of 8.5 years. The analyzes were based on 531 subjects (mean age at baseline: 37+/-7 years, 50% women and 42% non-smokers), recruited at two French centers participating in the European Community Respiratory Health Survey. Lung function was expressed as a percentage of predicted FEV1. CRP was measured centrally, by means of a highly sensitive assay. In cross-sectional analysis, FEV1 as a % of predicted values was negatively associated with serum CRP concentration (P=0.002). Multivariate adjustment did not alter these results (P=0.002). In longitudinal analysis, annual FEV1 decline tended to increase from the lower to the upper tertile for baseline CRP concentration but the association was borderline significant (P=0.14). Mean values of annual FEV1 decline were 26+/-32, 31+/-32, and 34+/-32 ml/year for the lower, middle and upper tertiles of baseline CRP concentration, respectively, after adjusting for potential confounders (P=0.09). Changes in CRP levels during follow-up were associated with annual FEV1 decline. The mean annual FEV1 declines in subjects with increasing CRP, in those with stable CRP and in those with decreasing CRP were 36+/-31, 30+/-31 and 24+/-31 ml/year, respectively (P<0.001). These findings were not affected by adjustment for potential confounders (P=0.002). In conclusion, increases in CRP levels over time were associated with a steeper FEV1 decline.